Download CHF - The New Chronic Disease

CHF - The New Chronic
Disease
Vinaya B. Chepuri, MD, FACC
WWMG Dept. of Cardiology
Medical Director of Medical Cardiology PRMC-E
November 1, 2010
Objectives
Discuss the step-wise improvement in the
long-term outcomes of heart failure patients.
Discuss latest advances in management of heart
failure patients.
Discuss practice guidelines for management of
patients with heart failure.
Discuss outpatient strategies and “teamconcept” used to treat heart failure patients.
Definition of Heart Failure (HF)
• HF is a syndrome caused by cardiac
dysfunction, generally resulting from
myocardial muscle dysfunction or loss and
characterized by LV dilation or hypertrophy.
• Whether the dysfunction is primarily
systolic or diastolic or mixed, it leads to
neurohormonal and circulatory
abnormalities, usually resulting in
characteristic symptoms…
Definition of Heart Failure (HF)
• HF is usually progressive.
• The severity of clinical symptoms may vary
substantially during the course of the disease
process and may not correlate with changes
in underlying cardiac function.
• Although HF is progressive and often fatal,
patients can be stablized, and myocardial
dysfunction and remodeling may improve,
either spontaneously or as a consequence of
therapy.
Risk Factor Management
QuickTim e™ and a
decom pres s or
are needed to s ee this picture.
Pre-load and Afterload Reduction
• V-Heft Study published in the mid-1980’s
was the proof of concept with improved
survival with Hydralazine and nitrates.
• Ace-Inhibitors (ACEI) subsequently showed
improved efficacy compared to Hydralazine
and nitrates. First ACEI trial to show
efficacy was CONSENSUS Trial in late 1980’s
with Enalapril. Multiple trials subsequently
have replicated this findings.
Neurohormonal Blockade
• ACEI are recommended for all patients with
current or prior symptoms of HF and
reduced LVEF, unless contraindicated. (Class
I, Level of Evidence:A)
• Angiotensin II receptor blockers (ARB’s) are
recommended in patients with current or
prior symptoms of HF and reduced LVEF
who are intolerant to ACEI. (Class I, Level of
Evidence:A)
Neurohormonal Blockade
• Beta-Blockers (using 1 of 3 proven to reduce
mortality, i.e., bisoprolol, carvedilol, and
sustained release metoprolol succinate) are
recommended for all stable patients with
current of prior symptoms of HF and
reduced LVEF, unless contraindicated (Class
I, Level of Evidence:A).
Avoidance of certain drugs
• Drugs known to adversely affect the clinical
status of patients with current or prior
symptoms of HF and reduced LVEF:
– NSAID’s
– Most antiarrhythmic drugs
– Most Calcium channel blocking drugs
(Class I, Level of Evidence:B)
Implantable cardioverterdefibrillator (ICD)
• ICD therapy is recommended for primary
prevention of sudden cardiac death to reduce
total mortality in:
– Patients with non-ischemic dilated
cardiomopathy
– Ischemic heart disease
• LVEF <35% (at least 40 days post MI)
• NYHA functional class II or III symptoms while
receiving chronic optimal medical therapy
– Who have reasonable expectation of survival
with a good functional status for more than 1
year.
Implantable cardioverterdefibrillator (ICD)
• An ICD is recommended for secondary
prevention to prolong survival in patients
with current or prior symptoms of HF and
reduced LVEF:
– History of cardiac arrest
– Ventricular fibrillation
– Hemodynamically destabilizing ventricular
tachycardia.
Class I, Level of Evidence:A
Cardiac Resynchronization
Therapy (CRT)
• CRT (with or without ICD) is indicated in:
– Patients with LVEF < 35%, sinus rhythm, and
NYHA class II
– Ambulatory, class IV symptoms despite
recommended, optimal medical therapy and
who have cardiac dyssynchrony (currently
defined as a QRS duration > 0.12 seconds)
Class I, Level of Evidence:A
Chronic Ventricular Pacing
• CRT is reasonable in patients with:
– For patients with LVEF < 35% with NYHA class
III or ambulatory class IV symptoms who are
receiving optimal recommended medical
therapy
and
– Frequent dependence on ventricular pacing
Class IIa, Level of Evidence: C
Hydralazine and Nitrates in
African-Americans
• The combination of hydralazine and nitrates
is recommended:
– Patients self-described as African-Americans,
with moderate-severe symptoms on optimal
therapy with ACEI, beta-blockers and diuretics.
Class I, Level of Evidence: B
Hydralazine and Nitrates in
patients already on ACEI and BB
• Reasonable in patients with:
– Reduced LVEF who are already taking an ACEI
and beta-blocker for symptomatic HF and who
have persistent symptoms. (Class IIa, Level of
Evidence: B)
– Current or prior symptoms of HF and reduced
LVEF who cannot be given an ACEI or ARB
because of drug intolerance, hypotension or
renal insuffiency. (Class IIb, Level of Evidence:
C)
Atrial Fibrillation
• It is reasonable to treat patients with atrial
fibrillation and HF with a strategy to
maintain sinus rhythm or with a strategy to
control ventricular rate alone. (Class IIa,
Level of Evidence: A).
ARB’s
• ARB’s are reasonable alternatives to ACEI as
first-line therapy for patients with mild to
moderate HF and reduced LVEF, especially
for patients already taking ARB’s for other
indications. (Class IIa, Level of Evidence: A)
• The addition of an ARB may be considered
in persistently symptomatic patients with
reduced LVEF who are already being treated
with conventional therapy. (Class IIb, Level
of Evidence: B)
Digitalis
• Digitalis can be beneficial in patients with
current or prior symptoms of HF and
reduced LVEF to decrease hospitalizations
for HF. (Class IIa, Level of Evidence: B)
Aldosterone Antagonist
• Addition of an aldosterone antagonist
(spironolactone or eplerenone) is
recommended:
– Selected patients with moderately severe to
severe symptoms of HF and reduced LVEF
– Who can be carefully monitored for preserved
renal function and normal potassium
concentration. Creatinine should be < 2.5 mg/dl
in men or < 2.0 mg/dl in women and K < 5.0
mEq/l.
(Class I, Level of Evidence:B)
Anticoagulants and
Antiplatelet agents
• Treatment with warfarin (goal INR=2.0-3.0)
is recommended for all patients with HF and
chronic or documented, paroxysmal a-fib
unless contraindicated.
Class I, Level of Evidence:A
• … or a history of systemic or pulmonary
emboli, including stroke or TIA unless
contraindicated.
Class I, Level of Evidence:C
CLASS III Recommendations
• Routine combined use of an ACEI, ARB and
aldosterone antagonist. (Level of Evidence:C)
• Calcium channel blocking drugs are not
indicated routinely. (Level of Evidence: A)
• Nutritional supplements as treatment for HF.
(Level of Evidence: C)
• Hormonal therapies other than to replete
deficiencies. (Level of Evidence: C)
Infusion of Positive Inotropic
Agents
• Long-term use of an infusion of a positive
inotropic drug:
– May be harmful and is not recommended for
patients with current or prior symptoms of HF
and reduced LVEF
– May be used as palliation for patients with endstage disease who cannot be stabilized with
standard medical treatment.
Class III, Level of Evidence: C
Infusion of Positive Inotropic
Agents
Preserving End-Organ Performance
I IIa IIb III In patients with clinical evidence of hypotension associated
with hypoperfusion and obvious evidence of elevated cardiac
filling pressures (e.g., elevated jugular venous pressure;
elevated pulmonary artery wedge pressure), intravenous
inotropic or vasopressor drugs should be administered to
maintain systemic perfusion and preserve end-organ
performance while more definitive therapy is considered.
I IIa IIb III Invasive hemodynamic monitoring should be performed to guide
therapy in patients who are in respiratory distress or with clinical
evidence of impaired perfusion in whom the adequacy or excess
of intracardiac filling pressures cannot be determined from
clinical assessment.
23
Transition to Outpatient Care
Discharge Instructions
I IIa IIb III
Comprehensive written discharge
instructions for all patients with a
hospitalization for HF and their
caregivers is strongly
recommended, with special
emphasis on the following 6
aspects of care:
24
Transition to Outpatient Care
I IIa IIb III
1. Diet
2. Discharge medications, with a special focus on
adherence, persistence, and uptitration to
recommended doses of ACE inhibitor/ARB and
beta-blocker medication
3. Activity level
4. Follow-up appointments within 5 to 7 days or
discharge from the hospital
5. Weight monitoring
6. What to do if HF symptoms worsen
25
Education and Counseling
• The majority of the HF care is done at home
by the patient and family or caregiver.
• Comprehensive education and counseling
are the foundation for all HF management.
• The goals of education and counseling are to
help patients, their families and caregivers
acquire the knowledge, skills, strategies, and
motivation necessary for adherence to the
treatment plan and effective participation in
self-care.
Education and Counseling
• Patients with HF and family members or
caregivers should receive individualized
education and counseling that emphasizes selfcare.
• This education and counseling should be
delivered by providers using a team-approach in
which nurses with expertise in HF management
provide the majority of education and
counseling, supplemented by physician input
and, when available and needed, input from
dietitians, pharmacists and other health care
providers.
Class I, Level of Evidence: B
Education and Counseling
• Patients’ literacy, cognitive status, psychological state,
culture and access to social and financial resources
should be taken into account for optimal education and
counseling.
• Cognitive impairment and depression are common in
HF and can seriously interfere with learning, patients
should be screened for these.
• Appropriate interventions, such as supportive
counseling and pharmacotherapy, are recommended
for those patients found to be depressed.
• Patients found to be cognitively impaired need
aditional support to manage their HF.
Class I, Level of Evidence: C
Education and Counseling
• Frequency and intensity of patient education
and counseling vary according to the stage of
illness.
• Patients in advanced HF or with persistent
difficulty adhering to the recommended
regimen require the most education and
counseling.
• Repeated exposure to material is essential
because a single session is never sufficient.
Class I, Level of Evidence: B
Education and Counseling
•
During the care process patients should be asked
to:
1. Demonstrate knowledge of the name, dose and purpose
of each medication.
2. Sort foods into high- and low-sodium categories.
3. Demonstrate their preferred method for tracking
medication dosing.
4. Show provider daily weight log.
5. Reiterate symptoms of worsening HF
6. Reiterate when to call the provider because of specific
symptoms or weight changes.
Class I, Level of Evidence: B
Education and Counseling
•
During acute care hospitalization, only essential
education is recommended, with the goal of
assisting patients to understand HF, the goals of its
treatment, and post-hospitalization medication
and follow-up regimen.
• The above education should be supplemented and
reinforced within 1-2 weeks after discharge and
continued for 3-6 months and reassessed
periodically.
Class I, Level of Evidence: B
Disease Management Program
•
Patients recently hospitalized for HF and
other patients at high risk should be
considered for referral to a comprehensive
HF disease management program that
delivers individualized care.
Class IIa, Level of Evidence: A
Disease Management Program
•
High risk patients include patients with:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Renal insufficiency
Low cardiac output state
Diabetes
Chronic Obstructive Pulmonary Disease
Persistent NYHA Class III or IV symptoms
Frequent hospitalizations for any cause
Multiple active comorbidities
History of depression or cognitive impairment
Persistent nonadherence to therapeutic regimens
Class IIa, Level of Evidence: A
Disease Management Program
•
Components or a HF Disease Management Program
should include:
1.
Comprehensive education and counseling individualized to
patient needs.
2. Promotion of self-care, including self-adjustment of
diuretic therapy in appropriate patients
3. Emphasis on behavioral strategies to increase adherence
4. Vigilant follow-up after hospital discharge or after periods
of instability
5. Optimization of medical therapy
6. Increased access to providers
7. Early attention to signs and symptoms of fluid overload
8. Assistance with social and financial concerns.
(Class I, Level of Evidence: B).
Disease Management Program
•
Heart Failure Disease Management program
should include integration and coordination of
care between the primary care physician, HF
care specialists and with other agencies, such
as home health, cardiac rehabilitation, etc.
Class I, Level of Evidence: C
Advance Directives and
End-of Life Care
•
•
It is mandatory that discussions about advance
directives occur and end-of-life care occur
after full and appropriate application of
evidence-based pharmacologic and
nonpharmacoligic treatments.
Moreover, clinicians must recognize that use
of end-of-life care does not mandate
abandonment of HF therapies, which may
effectively ease symptoms and continue to
improve quality of life.
•
•
•
•
Advance Directives and
End-of Life Care
Patient’s status should be optimized medically and
psychologically before discussing the possibility that
end-of-life care is indicated.
The decision to declare a patient as an appropriate
candidate for end-of-life care should be made by
physicians experienced in the care of patients with
HF.
End-of-life management should be coordinated with
the patient’s primary care physician.
As often as possible, discussions regarding end-of-life
care should be initiated while the patient is still
capable of participating in decision making.
Class I, Level of Evidence: C
Get With The Guidelines-Heart Failure
• “It’s more than a title or even
a statement; it’s a call to
action.”
GWTG-HF
• ACHIEVEMENT
MEASURES
–
–
–
–
–
ACEI/ARB at discharge
BB at discharge
DC instructions
Measure LVEF
Smoking Cessation
• QUALITY MEASURES
– Aldosterone Antagonist at
DC
– Anticoag for Afib
– CRT place or prescribed
– DVT prophylaxis
– Evidence-based BB at DC
– Hydralazine at DC
– ICD placed or prescribed
– Flu and pneumonia vaccines
• REPORTING MEASURES
–
–
–
–
BP control at DC
Diabetes Treatment
Diabetes Teaching
Follow-up visit in 7 days or
less
– Lipid Lower Meds at DC
– Omega-3 Fatty acid
supplement at DC
Transition to Outpatient CareDischarge Instructions
I IIa IIb III
1. Diet
2. Discharge medications, with a special focus on
adherence, persistence, and uptitration to
recommended doses of ACE inhibitor/ARB and
beta-blocker medication
3. Activity level
4. Follow-up appointments within 5 to 7 days or
discharge from the hospital
5. Weight monitoring
6. What to do if HF symptoms worsen
40
Get With The Guidelines-Heart Failure
•
•
Discharge instructions include all of the measures
on the previous slide.
All of the measures have to be achieved to receive
credit for appropriate “discharge instructions.”
Medicare and Joint Commission Heart Failure Core Measures
Providence Regional Medical Center 2009-2010
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Discharge instructions
Evaluation of LVS Function
ACEI or ARB for LVSD
Adult smoking cessation advice/counseling
Data Source: Medicare Hospital Compare (2009 CMS data )
http://www.hospitalcompare.hhs.gov/Graphs/Hospital-OOCGraph.aspx?hid=500014&stype=MEDICAL&mCode=GRP_2&MTorAM=READM
Providence Health System - CMS Hospital Compare:
30-day Risk Standardized Readmission Rate
and 95% Interval Estimate for CHF
Risk Standardized Readmission Rate (%)
35
30
25
20
20.6 20.6
19.6 20.1 20.2
24.4 24.7 24.7 24.7
23.6 23.7 23.7 24.2
23.4
23.3
22.7
21.6 22.0 22.0 22.2
25.5 25.8 25.8
15
10
5
0
* Significantly Lower than National Rate
2009 Data
Data Source: Medicare Hospital Compare (2009 CMS data )
http://www.hospitalcompare.hhs.gov/Graphs/Hospital-OOCGraph.aspx?hid=500014&stype=MEDICAL&mCode=GRP_2&MTorAM=READM
25%
Heart Failure 30 day Unadjusted
All Cause Readmission Rate Monthly Trend
20%
15%
10%
5%
0%
January through August 2010 = 14.9%
• Multidisciplinary Team
includes
•
•
•
•
Primary physician clinics
Home health services
Skilled nursing facilities
Hospital staff which
include
• Cardiologists
• Hospitalists
• Pharmacy
• Nutrition services
• Nursing leaders
• Care management
• ED staff
• Clinical data analyst
• Community Education
targeted at
• senior centers,
• libraries,
• skilled nursing facilities
• Innovations
• Transition coach to assist
high risk patients in their
transition to home
• Medication management
clinic to discuss and
reconcile medications
Reducing Readmissions Project Aims
•
•
•
•
Hospitalist consultation on patients in the ED
Screening of patients for palliative care needs
Stratification of patients into 4 “risk” categories
Early/immediate involvement of transition
coaches for patients at high risk for readmission
• Coordination of post-discharge follow up phone
calls for all patients
• Creation of an outpatient Medication
Management Clinic in conjunction with the AntiCoag Clinic??
THANKS!!!
• Heart Failure Quality Team at PRMC-E
• Julie McDonald
PRMC-E, Decision Support
QUESTIONS?
• D/C planner / MSW
• TCRN f/u to ensure
smooth handoffs
• HH Liaison
• D/C instructions
• HH RN visit
within 48hrs
High Risk
Homebound
• D/C instructions
• Smooth handoffs
• Community outreach
programs to support
SNF staff
• SNF-ist program?
SNF Bound
• D/C Instructions
• Return to Med Mgmt
Clinic 3-7 days postD/C
• TCRN Phone followup to ensure MMC
contact and PCP appt
made and kept.
High Risk NonHomebound
Palliative
Care
• Team ‘P’ referral
• D/C instructions
• Develop palliative care
plan
• Team ‘P’ monitors handoffs to PCP
Progress to Date
• Instituted Hospitalist Consultation in ED
• Risk Screening underway – admitting orders
• Transition RN – in the process of hiring and
developing protocols and procedures
• 5 day Follow-up - good commitment from TEC, PPG,
GHC, Molina, Access clinic, and Tulalip
• Medication Management & Reconciliation – Clinic
ready for patients on October 18th
• Home Health - Goal is to see patients within 48hrs of
discharge
Current and Planned Measure of Success
Overall readmission rate within 30 days
Process measures to be developed over course of
project:
Percent of patients in the ‘yellow’ category
Use of risk stratification tool
Readmissions from SNF
Trend of readmission rates stratified by category
Trends of readmission rates by nursing unit
Trends of readmission rates by physician specialty/section
Volume of MHT consults performed in the ED
Readmission 100%
Risk
90%
Category
80%
Distribution
70%
60%
50%
40%
30%
20%
10%
0%
7/4
7/11 7/18 7/25
8/1
8/8
JULY
(Order set implemented)
9/5
8/22 8/29
9/5
AUGUST
9/12 9/19 9/26 3-Oct
September
October
Palliative
6
1
2
6
6
1
3
6
5
3
2
2
2
3
High Risk
16
24
32
22
41
28
44
26
26
24
35
46
44
41
Low Risk
23
20
22
17
19
26
19
31
30
10
24
32
20
22
SNF / Transfer
27
27
21
15
26
21
28
19
18
16
29
32
26
23
Not Documented 130
136
113
101
104
126
110
103
92
71
99
113
128
102
Risk Scoring Documentation by Hospitalist
June 2010 - Present
Null
25
14
1
15
9
2
15
14
6
11
1
15
23
7
4
10
11
18
20
15
10
15
6
4
Blue
2
13
12
11
13
10
2
8
7
8
8
11
8
6
10
8
5
8
6
6
7
1
1
1
9
2
7
10
1
8
7
9
4
8
1
6
7
9
3
7
4
38
64
75
4
6
11
7
Yellow
3
7
12
8
9
2
9
11
7
1
6
3
9
Red
5
9
1
7
Green
47
42
38
41
38
33
30
34
27
27
28
22
24
24
25
21
23
20
23
22
SNF Readmission Rate & Case Volumes
Jan.- June 2010
Cases
160
153
IP Cases
150
30 Day Readmission Rate 30 Day readmission Rate
Rate
70%
150
60.0%
140
60%
120
100
100
38.7%
80
60
40
20
0
50%
31.3%
24.2%
32.0%
40%
76
28.9%
21.6%
37
Overall SNF
Readmission
Rate 28.4%
34
8.8%
30%
20%
15.6%
32
20
10%
5
1
0%
Get With The Guidelines-Heart Failure
•
Achievement Measures:
1.
2.
3.
4.
Measure/Document LV Function
Discharge Instructions
ACEI/ARB at Discharge
Beta-Blocker at Discharge
5.
Smoking Cessation Teaching
Get With The Guidelines-Heart Failure
•
Quality Measures:
1.
2.
3.
4.
Aldosterone Antagonist at Discharge
Anticoagulation for Atrial Fibrillation
CRT Placed or Prescribed at Discharge
DVT Prophylaxis
5. Evidence-Based Specific Beta-Blockers
6. Hydralazine/Nitrate at Discharge in the appropriate
patient
7. ICD Placed or Prescribed at Discharge
8. Influenza Vaccination During Flu Season
9. Pneumococcal Vaccination